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Teaching Physicians
PROFESSIONAL FEE BILLING COMPLIANCE PROGRAM
POLICIES & PROCEDURES
For
TEACHING PHYSICIANS
Summary Handbook
UNIVERSITY OF CALIFORNIA, SAN DIEGO
School of Medicine
I. INTRODUCTION
II. PROGRAM OBJECTIVES
III. ADMINISTRATIVE OVERVIEW
A. Role of The Regents
B. Office of The President
C. Systemwide Compliance Committee
D. Dean, UCSD School of Medicine
E. UCSD Health Sciences Corporate Compliance Officer
F. Campus Corporate Compliance Committee
G. Clinical Departments
H. Role of the Physician
I. Help Line and Confidential Message Reporting Line (Hot Line)
J. Role of Audit Management Advisory Services
IV. CLINICAL FELLOW POLICY
V. STANDARDS OF BUSINESS CONDUCT
VI. GENERAL POLICIES and PROCEDURES
A. Documentation
B. Record Retention
C. Signatures
D. Coding Defined
E. Refunds and Fines
F. Disciplinary Measures
VII. TEACHING PHYSICIAN GUIDELINES
A. Evaluation and Management Services
B. Consultations
C. Anesthesia
D. Diagnostic Tests
E. Endoscopies
F. Surgical Services
G. Psychiatry
H. Time-Based Services
I. Discharge-Day Management
J. Maternity
K. Teaching Modifier
Rev.: 10/00
PROFESSIONAL FEE BILLING
COMPLIANCE PROGRAM
POLICIES AND PROCEDURES
I. INTRODUCTION
The University of California Health Sciences Campus Systemwide Professional Fee Billing Compliance Plan Guidelines were adopted by The Regents of the University of California for implementation at all University of California Schools of Medicine. These Guidelines mandate certain supplementary procedures for implementation at the UCSD School of Medicine. In adopting our compliance plan, the School of Medicine at UCSD affirms The Regents philosophy of University compliance with applicable laws, regulations, and University policies that impact professional fee billing. A separate compliance program is under development for the UCSD Medical Center.
II. PROGRAM OBJECTIVES
The UCSD Professional Fee Billing Compliance Program is designed to accomplish the following objectives: (1) to familiarize physicians and non-physician employees involved with professional fee billing about applicable laws, regulations, and University policies regarding professional fee billing; (2) to promote programs and practices designed to provide reasonable assurance that all such individuals and departments will follow such laws, regulations, and policies; (3) to reduce legal and financial risks; and (4) to provide a mechanism for communication concerning compliance.
III. ADMINISTRATIVE OVERVIEW
As mandated by The Regents of the University of California, the UCSD School of Medicine has developed a Professional Fee Billing Compliance Program. This program has been created as a resource to assist the University and faculty in understanding, interpreting and following applicable billing rules, regulations and policies. The UCSD Professional Fee Billing Compliance Program has implemented a strategy of staff and physician education, communication, policy and procedure development, documentation and billing interpretation, medical record reviews with physician feedback, departmental and faculty input, legal and audit guidance, and administrative leadership. In this era of heightened accountability, the School of Medicine is committed to providing the necessary administrative tools and structure to maintain compliance with governmental professional services regulations. The organizational structure of University-wide compliance is as follows:
A. Role of The Regents
The Regents, as the governing body of the University of California, have ultimate authority for compliance matters covered by the University's Guidelines and Procedures.
B. Office of The President
Within the UC Office of the President, the Vice President of Clinical Services Development has responsibility for reviewing campus compliance policies and procedures to ensure that they have been appropriately adopted and are implemented in accordance with the University's Guidelines.
C. Systemwide Compliance Committee
The UC Systemwide Compliance Committee is composed of the Vice President for Clinical Services Development (Chair), University General Counsel, University Auditor, and representatives from the other UC health science campuses including the UCSD School of Medicine Dean for Clinical Affairs. This Committee has authority to develop and adopt policies consistent with the University's Compliance Guidelines.
D. Dean, UCSD School of Medicine
The Dean, delegating to the Dean for Clinical Affairs, has overall responsibility for compliance activities, and the development and implementation of the Professional Fee Billing Compliance Program for the UCSD School of Medicine and its affiliated institutions.
E. Corporate Compliance Officer
The Dean of the UCSD School of Medicine has designated a campus Corporate Compliance Officer (CCO). This individual, as chair of the campus Corporate Compliance Committee, is responsible for: (1) implementing policies and procedures adopted by The Regents and the UCSD School of Medicine; (2) approving all campus related billing manuals, forms, billing and medical record documentation policies and procedures, and training related materials; (3) developing and / or implementing all School of Medicine programs designed to familiarize faculty and staff with laws, regulations, and official interpretations that impact professional fee billing for services provided under private, state, and federally funded health care programs; and (4) periodic reviews of professional fee billing activities, to assess the proficiency of the physician, non-physician provider, or staff biller/coder in generating professional fee claims consistent with documentation and regulatory requirements.
F. Corporate Compliance Committee
The Dean has appointed a Health Sciences Corporate Compliance Committee consisting of selected clinically active faculty, the Dean for Clinical Affairs, the Director of Audit Management Advisory Services, the UCSDMC Director of Risk Management, the Medical Group Billing Director, and selected School of Medicine administrators to support and advise the CCO. Campus counsel assistance is requested as appropriate. The Corporate Compliance Committee, with the CCO as the chair, meets regularly concerning compliance activities.
G. Clinical Departments
The Chair of each clinical department shall provide liaison to the CCO, and this function shall not be delegated. Each Chair is responsible for developing and implementing departmental compliance policies and procedures within the framework of the University's Guidelines and UCSD Policies and Procedures, and to ensure that departmental physicians and staff adhere to all compliance policies. The CCO will report issues of concern regarding professional fee activity to the Chair, and the Chair will be responsible for ensuring departmental compliance.
H. Role of the Physician
The accelerated enforcement climate in health care has made it increasingly clear that physicians are being held more accountable for the stringent rules and complex interpretations regarding professional services. Since professional services are billed in the name of the rendering physician, individual physicians who render patient care services are being singled out by governmental agencies as bearing the primary responsibility for ensuring compliance with applicable laws and regulations. Regental policy states that individual physicians bear the primary responsibility for ensuring compliance with applicable laws and regulations concerning professional fee billing. Other staff, such as billing office personnel, are responsible for those billing functions that they carry out.
I. Help Line and Confidential Message Reporting Line
UCSD has established a help line (619-543-3344) through which personnel can raise questions and receive appropriate guidance on professional fee billing issues and concerns. The Corporate Compliance Manager manages the help line. A Confidential Message Reporting Line (Hot Line) was established to take calls regarding possible fraud, such as misuse of assets, false billings, conflict of interest, or other compliance issues. Faculty, staff and students are encouraged to report concerns directly to their immediate supervisors, managers or department heads. When this approach is not viable, the UCSD Confidential Message Reporting Line (Toll Free 877-319-0265) provides a secondary confidential alternative for reporting concerns requiring University review and action.
J. Role of Audit Management Advisory Services
UCSD Audit Management Advisory Services is responsible for providing external audit liaison services for any professional fee billing external reviews, audits, investigations, subpoenas, or requests for access to University documents. All external inquiries from outside representatives must be directed to Audit Management Advisory Services. In addition, employees should report instances of potential improper billing activity to Audit Management Advisory Services for evaluation in accordance with the UCSD Policy and Procedure 460-5 "Reporting and Investigating Improper Governmental Activities, Misuse of University Resources, Fraud and Other Financial Irregularities".
IV. CLINICAL FELLOW POLICY
At UCSD, physician trainees who have completed residency training and enroll in subsequent programs leading to a certificate of special competence in a specific medical subspecialty are referred to as "clinical fellows".
The Medicare program has specifically stated that it is inappropriate to submit bills for services rendered exclusively by a Clinical Fellow unless qualified to do so under a "moonlighting" agreement. "Clinical Fellow" refers to individuals enrolled in a graduate medical education training program that is approved and recognized by the Accreditation Council for Graduate Medical Education (ACGME), or the American Board of Medical Specialties (ABMS) as an "approved and recognized" graduate medical education program or where a certificate of added qualifications (CAQ) is possible.
A "clinical fellow", who is enrolled in a departmental training program that is not recognized by the ACGME or ABMS as an "approved" graduate medical education program and/or where a CAQ is not expected, may bill for professional services providing they have the necessary credentials and privileges of the UCSD Medical Center, UCSD School of Medicine and the UCSD Medical Group.
"Moonlighting" agreement refers to an approved contract for separate, identifiable services that may qualify for a Part-B billing, if certain conditions are
met.
V. STANDARDS OF BUSINESS CONDUCT
The preservation of the highest standards of integrity and ethical principles is vital to the successful discharge of the responsibilities of all physician and non-physician employees of the University of California. The
University's reputation is the collective reputation of its employees; therefore, it is essential that each employee meet the highest standards of legal and ethical conduct. The University has appropriate, informative, and ethical standards in its professional fee billing policies and procedures that are designed to produce claims for professional fee billings that are proper and accurate. To learn more about the ethical standards, employees are expected to receive and read the "UCSD Health Sciences Corporate Compliance Handbook and Code of Conduct".
All members of the UCSD School of Medicine community are expected to conduct their professional activities with honesty, integrity, fairness, and in a good faith manner that will reflect well upon the individual and the University. It is essential that all personnel perform their job duties in compliance with applicable laws, University policies, and protect the confidentiality of patient and institutional information. Employees are assured that to raise a concern or report misconduct is expected, accepted, and protected
behavior. To review a complete version of the Standards of Business
Conduct, please see the Standards of Conduct.
VI. GENERAL POLICIES AND PROCEDURES
The following policies and procedures are to be used at this institution when documenting professional services.
A. Documentation
Medical record documentation is required to record pertinent facts, findings, and observations about an individual's health history including past and present illnesses, examinations, tests, treatments, and outcomes. The record should chronologically document the care of the patient, and is an important element contributing to the quality of care. The medical record is also considered to be the basis for assessing patient health over time; appropriate utilization review and comparisons, a data source for research and education; a legal document for risk management; and establishes the supporting elements needed for professional fee billing.
As a general rule, physicians must clearly document (in legible handwriting or in a signed dictated note) their presence, and level of participation in the services provided. Medical record documentation should be completed immediately following patient services or within sufficient time to recollect the key portions of the services provided. Whoever dictates a note, report, or entry, shall sign that note, report, or entry. A medical record is considered a legal document; therefore, handwritten entries must be made in ink and must be legible.
B. Record Retention
Because the mission of the University includes clinical research, as well as patient care and teaching, UCSD Medical Record Retention Policy mandates that medical records are to be kept 10 years for adults, 25 years for minors (under age 18), and 30 years beyond experiment for any human experimentation (experimental drugs and devices). UCSD Medical Group billing records for professional fee services shall be retained for a minimum of 10 years.
C. Signatures
Either the full physician signature, or the first initial of the physician and a complete physician last name is required. Practitioners using a computerized signature to authenticate entries must sign a statement they alone will use it.
D. Coding Defined
Copyrighted by the American Medical Association, the "Physicians' Current Procedural Terminology, Fourth Edition" (CPT-4) is a listing of descriptive terms and identifying codes for reporting medical, surgical, and diagnostic services performed by physicians. This five digit numeric coding methodology is not only utilized for billing purposes, but provides a uniform language applicable to patient care education, research, and utilization comparisons. The "International Classification of Diseases, 9th Revision" (ICD-9), is a numeric coding system describing diseases, symptoms, conditions, complications, external causes, as well as drugs and chemicals.
HCPCS (pronounced "hickpicks") is the Health Care Financing Administration Common Procedure Coding System utilized when billing Medicare.
Utilizing the above coding systems, the UCSD School of Medicine is committed to submitting only compliant billings for professional fees; and further, strives to provide reasonable assurance concerning compliance with conditions of payment and encounter data reporting under managed care plans.
E. Refunds and Fines
As is current practice, amounts identified as a result of inaccurate billing are repaid as soon as possible. It is the policy of The Regents that repaid amounts, including fines and penalties, be recovered from the responsible individuals, departments, and/or institutions. Typically, refunds are subtracted from future amounts credited to the individual, department or institution.
F. Disciplinary Measures
UCSD reserves the right to take corrective action and disciplinary measures against any employed physician or other provider, who fails to comply with University wide or UCSD professional fee billing and documentation guidelines, or with federal Medicare regulations governing professional fee billing. Corrective action refers to that which may be necessary to remedy errors in billings including fines and penalties. Disciplinary action may be imposed for conduct found to violate University rules, regulations, and policies. Corrective action will not preclude sanctions or disciplinary measures in accordance with the 1) UCSD Medical Center Bylaws, Rules and Regulations, 2) the UC Faculty Code of Conduct, and 3) the UCSD Academic Senate
Bylaws.
VII. TEACHING PHYSICIAN GUIDELINES
The basic requirements needed when seeking payment from Medicare is commonly referred to as the "general rule". The "general rule", as described by the American Association of Medical Colleges (AAMC), is "if a resident participates in a service furnished in a teaching setting, a physician fee schedule payment is made only if a teaching physician is present to perform or observe the resident perform the key portion of any service or procedure for which payment is sought." Information recorded within the medical record must demonstrate the teaching physician's presence and level of participation in the service. For billing purposes, the medical record information must also support the presence of the teaching physician during the critical/key (most important treatment-determining, interpretation making, defining technology or technique) portion of the service or procedure, and his/her participation.
The following section is a composite of jointly developed medical record documentation guidelines for Teaching Physicians by the American Medical Association (AMA) and the Health Care Financing Administration (HCFA), as well as professional interpretations of Medicare teaching physician regulations. A UCSD Medical Group teaching physician is a physician, other than a resident or fellow in an approved program, who has clinical privileges at UCSD Medical Center, a faculty appointment at the UCSD School of Medicine, and who involves residents in the care of their patients.
A. Evaluation and Management Services
At a minimum, medical record notes should include: (1) relevant history of present illness and prior diagnostic tests; (2) major findings of physical examination; (3) assessment, clinical impression or diagnosis; and (4) plan of care. When a patient is re-admitted for subsequent hospital care or for established patient visits, the teaching
physician's personal note must highlight at least two of the following three components: (1) relevant history; (2) major findings of physical examination; (3) medical decision-making (assessment, impression, diagnosis, or plan of care). When the teaching physician is performing services with a resident(s), he or she may document brief summary comments that tie into each resident's entry, which either confirm or revise each KEY element of the service(s) provided. For billing purposes the teaching physician must be present during the portion of a service that determines the level of service billed.
B. Consultations
A consultation is a service provided by a physician whose opinion or advice regarding the evaluation and or management of a specific problem is requested by another faculty physician or other appropriate source. The request and reason for a consultation must be documented in the patient's medical record. What the consultant did or reviewed in order to reach an opinion, and the consultant's opinion must be documented in the progress notes of the medical record, or in a consultation report located in the medical record. A written opinion or recommendation must be provided to the requesting physician. The consultant's notes and/or opinion must also be accompanied by an appropriate signature.
C. Anesthesia
The teaching anesthesiologist must be available to furnish services throughout the entire procedure. In order to bill for professional services, HCFA guidelines mandate that the teaching physician be present for induction, emergence, and all other critical or key portions of care. Documentation of care must be provided. The anesthesia record should include the signatures of all participants in the care of the patient, including the resident, CRNA and attending anesthesiologist. The teaching anesthesiologist must document the preoperative evaluation, presence and participation during the administration of anesthesia, including those portions of the service for which they are present and the extent of postoperative care.
D. Diagnostic Tests
The teaching physician shall either personally perform or review test results or materials and agree with or make changes and additions to the resident's interpretation. If a resident prepares and signs the interpretation, the teaching physician must indicate that he/she personally reviewed the material or results and the resident's interpretation and either agrees with it or edits the findings.
E. Endoscopies
For diagnostic endoscopy procedures, the medical record must document the teaching physician's presence during the procedure. For billing purposes, the teaching physician must be present for the entire viewing, which includes the scope insertion, diagnostic viewing, and scope withdrawal. (Note: this is for diagnostic endoscopy, and does not refer to therapeutic (surgical) procedures performed
endoscopically.)
F. Surgical Services
"Physical Presence" is one of the basics for surgical procedure documentation. The physician must assure documentation of his/her personal involvement and presence during the surgical procedure. If the teaching physician is present throughout the entire procedure, a personal notation of "key portions" by the teaching physician is not required; however, if the operative report is dictated by a resident, it should be noted that the teaching physician was present for the entire procedure. If the teaching physician is not present for the entire procedure then the teaching physician must: (1) personally document the key portion(s) of the procedure for which he/she was present; and (2) be immediately available throughout the entire event; and/or designate another physician to be immediately available. The presence or level of involvement by the teaching physician may be recorded in notes to the record by the teaching physician, resident, or operating room nurse. The teaching physician signature is required on operative notes.
Overlapping Surgeries require the teaching physician to document the key portions of each operation, and his/her presence and participation during those key portions. When all of the key portions of the initial procedure have been completed, the teaching physician may become involved in a second procedure. The teaching physician bill only for operations during which they were physically present for all of the key portions.
G. Psychiatry
For psychiatric services, the requirement for the presence of the teaching physician (psychiatrist) during the service must either be "in-person" or by concurrent observation: one-way mirror or video equipment.
H. Time-Based Services
Physicians must document time-based services that reflect the actual amount of time spent with the individual patient (e.g., face-to-face for office visits and unit/floor for inpatient hospital visits). The documentation must also summarize what services were performed during that time and the medical necessity for physician attendance throughout the time reflected.
I. Discharge Day Management
Generally on the day of a patient's discharge, the physician spends an added amount of time with the patient and the family communicating instructions to be followed upon discharge, future medical visits, and medication management. In addition to any final reviews of progress notes and the patient's physical condition, the amount of time spent with the patient and family discussing discharge instructions should be noted.
J. Maternity
The presence of the teaching physician during maternity procedures follows the same guidelines previously noted for surgical services. The physical presence requirement is applied to the delivery (key portion), and the teaching physician must document his/her involvement, presence, and availability at the time of delivery.
K. Teaching Modifier
Medicare mandates the use of HCPCS modifier (GC) for submission of Medicare claims when, "a service has been performed in part by a resident under the direction of a teaching physician." The use of this tracking modifier indicates that a resident was involved in the case and implicitly represents that the conditions for a Part B claim were satisfied. This modifier has no effect on the reimbursement received.
UCSD Health Sciences
PROFESSIONAL FEE BILLING COMPLIANCE PROGRAM
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